Healthcare Provider Details

I. General information

NPI: 1255866372
Provider Name (Legal Business Name): JACOBS RADIOLOGY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MAPLE AVE STE 2
ROCKVILLE CENTRE NY
11570-4259
US

IV. Provider business mailing address

24 MAPLE AVE STE 2
ROCKVILLE CENTRE NY
11570-4259
US

V. Phone/Fax

Practice location:
  • Phone: 516-865-1234
  • Fax:
Mailing address:
  • Phone: 516-865-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number257302-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID T JACOBS
Title or Position: OWNER
Credential: MD
Phone: 516-865-1234